Bipolar disorder mental health exam 3
therapeutic range for lithium toxicity
1.0 to 1.5 mEq/L (acute mania) •0.6 to 1.2 mEq/L (maintenance
what may exacerbate mania and should be administered only after bipolar symptoms are under control
ADHD agents
what is somewhat milder form of mania
hypomania
Self help for patient
1. Identify stressors and develop skills for coping with them 2. Avoid alcohol and recreational drugs 3. Develop regular sleep patterns. Sleep disturbances may signal the early phase of mania. 4. Take medications as ordered. 5. Join a support or self-help group.
Psychopharmacology for mania
Lithium carbonate - antimanic Anticonvulsants- carbamezepine Verapamil- calcium channel blacker Antipsychotics
If the patient will not take lithium, what other drug might the doctor prescribe?
Valproic acid (Depakote)
Mood
defined as a pervasive and sustained emotion that may have a major influence on a person's perception of the world
monitor for side effects of lithium which are
1. Drowsiness, dizziness, headache 2. Dry mouth, thirst, GI upset, nausea/vomiting 3. Fine hand tremors 4. Hypotension, arrhythmias, pulse irregularities 5. Polyuria, dehydration 6. Weight gain 7. Potential for toxicity
Cognitive therapy
1. The individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders. 2. The general goal in cognitive therapy is to assist the patient in identifying dysfunctional patterns of think and behaving. 3. Therapy focuses on changing "automatic thoughts "that occur spontaneously and contribute to the distorted effect. See examples on p. 443
what may or may not be apart of clinical picture of bipolar disorder
delusions or hallucination
Examples of mood
depression, joy, elation, anger, anxiety
substance - induced bipolar disorder
A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (e.g., ingestion of or withdrawal for a drug of abuse or a medication or other treatment).
bipolar disorder associated with another medical condition
Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition
bipolar II disorder
Characterized by bouts of major depression with episodic occurrence of hypomania. Has never met criteria for full manic episode. Box 17-2, Diagnostic Criteria for Hypomanic Episode, p. 431
cyclothymic disorder
Chronic mood disturbance At least 2-year duration Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either Bipolar I or II disorder. Box 17-3, Diagnostic Criteria for Cyclothymic Disorder, p. 432
Client/ family education for bipolar
nature of illness management of the illness support services evaluation
what do you ensure pt consume adequate amount of in diet with lithium toxicity
sodium and fluid
In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? a) Risk for injury related to excessive hyperactivity b) Disturbed sleep pattern related to manic hyperactivity c) Imbalanced nutrition, less than body requirements, related to inadequate intake d) Situational low self-esteem related to embarrassment secondary to high-risk behaviors
Correct answer: A According to Maslow's hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.
A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? a) Do not skimp on dietary sodium intake b) Have serum lithium levels checked every 6 months c) Limit fluid intake to 1,000 ml of fluid per day d) Adjust the dose if you feel out of control
Correct answer: A Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 ml of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium with resulting toxicity. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium and preventing toxicity
A suicidal client with a history of manic behavior is admitted to the ED. The client's diagnosis is documented as Bipolar I Disorder: Current Episode Depressed. What is the rationale for this diagnosis instead of a diagnosis of Major Depressive Disorder? a) The physician does not believe the client is suffering from major depression. b) The client has experienced a manic episode in the past. c) The client does not exhibit psychotic symptoms. d) There is no history of major depression in the client's
Correct answer: B The client's past history of mania and current suicide attempt support the diagnosis of Bipolar I Disorder: Current Episode Depressed. According to the DSM-5 criteria, a manic episode rules out the diagnosis of Major Depressive Disorder.
developmental implications: childhood and adolescence
Diagnosis is difficult. FIND tool
developmental implications: childhood and adolescence symptoms
Euphoric/expansive mood: extremely happy, silly, or giddy Irritable mood: hostility and rage, often over trivial matters Grandiosity: believes abilities to be better than everyone else's Decreased need for sleep: may sleep for only 4 or 5 hours per night and wake up feeling rested Pressured speech: loud, intrusive, difficult to interrupt Racing thoughts: rapid change of topics Distractibility: unable to focus on school lessons Increase in goal-directed activity/psychomotor agitation: activities become obsessive; increased psychomotor agitation
FIND tool
Frequency: symptoms occur most days in a week. Intensity: symptoms are severe enough to cause extreme disturbance. Number: symptoms occur 3 or 4 times a day. Duration: symptoms occur 4 of more hours a day
bipolar I disorder
Patient is experiencing, or has experienced a full syndrome of manic or mixed symptoms. May also have experienced episodes of depression Box 17-1, Diagnostic Criteria for Manic Episodes, p. 430
developmental implications: childhood and adolescence family interventions
Psychoeducation about bipolar disorder Communication training Problem-solving skills training
nursing diagnosis for bipolar
Risk for injury related to extreme agitation, and lack of control over purposeless and potentially injurious movements Risk for violence: self-directed or other-directed related to Manic excitement or Delusional thinking or Hallucinations or Impulsivity Imbalanced nutrition less than body requirements related to refusal or inability to sit still long enough to eat, evidenced by loss of weight Disturbed thought processes related to biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment Disturbed sensory perception related to biochemical alterations in the brain, and to possible sleep deprivation, evidenced by auditory and visual hallucinations. Impaired social interaction related to egocentric behavior evidenced by dominating the conversation during group time. Insomnia related to excessive hyperactivity and agitation evidenced by sleeping only 3 hours a night
Current recommendation for mania in children and adolescents is a
SGA (second generation antipsychotic).
symptoms may be categorized by degree of severity what are the stages
Stage I - Hypomania Stage II - Acute mania Stage III - Delirious mania
patient/ family education with lithium
Take the medication regularly Do not skimp on dietary sodium Drink 6 to 8 glasses of water each day Notify physician if vomiting or diarrhea occur Have serum lithium level checked every 1 to 2 months, or as advised by physician avoid excess use of beverages containing caffeine
Stage III - Delirious mania
a grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication a. Labile mood: panic anxiety b. Clouding of consciousness; disorientation c. Frenzied psychomotor activity d. Exhaustion and possible death without intervention
Nature of the illness- Client/ family education for bipolar
a. Causes of bipolar disorder - stress may trigger manic episodes b. Cyclic nature of the illness c. Symptoms of depression d. Symptoms of mania
support services Client/ family education for bipolar
a. Crisis hotline b. Support groups c. Individual psychotherapy d. Legal/financial assistance
Management of the illness Client/ family education for bipolar
a. Medication management - teach importance of taking medications b. Assertive techniques c. Anger management d. Stress management
mania
an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking
For depressive phase Use what
antidepressants with care (may trigger mania)
what will manic pt could be prescribed what along with lithium until the lithium takes effects
atypical anti psychotic
predisposing factors of bipolar
biologic theory (genetics, biochemical influcences, and physiologic influence) psychosocial theories developmental implications: childhood and adolescence
Types of Bipolar Disorders
bipolar I disorder bipolar II disorder cyclothymic disorder substance - induced bipolar disorder bipolar disorder associated with another medical condition
Initial symptoms of lithium toxicity include
blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea
bipolar is viewed as a disease of the
brain
Bipolar disorder is characterized by
by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.
Nursing Interventions are aimed at
maintaining a safe environment & administering medications) Protection from injury due to hyperactivity Protection from harm to self or others Restoration of nutritional status Progression toward resolution of the grief process Improvement in interactions with others Improvement in interactions with others Acquiring sufficient rest and sleep Structure, need limits, talk in simple short sentences, Trust is important.
Stage II - Acute mania
marked impairment in functioning; usually requires hospitalization. a. Elation and euphoria: a continuous "high" b. Flight of ideas: accelerated, pressured speech c. Hallucinations and delusions. d. Excessive motor activity e. Social sexual inhibition f. Little need for sleep
evaluation Client/ family education for bipolar
measured by the fulfillment of outcome criteria Has the client avoided personal injury? Has violence to client or others been prevented? Has agitation subsided? Have nutritional status and weight been stabilized? Have delusions and hallucinations ceased? Is the client able to make decisions about own self-care? Is behavior socially acceptable? Is the client able to sleep 6 to 8 hours per night and awaken feeling rested? Does the client understand the importance of maintenance medication therapy?
what is the number one treatment modality in treating bipolar disease
medication
Stage I - Hypomania
symptoms not sufficiently severe to cause marked impairment in social or occupational function to require hospitalization. a. Cheerful mood b. Rapid flow of ideas; heightened perception c. Increased motor activity
Lithium may modulate the effects
of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder.
outcome criteria for bipolar disorder
patient will remain free from injury
what do the onset of symptoms reflect
seasonal pattern
